School Asthma Action Plan by benbenzhou


More Info
									                            School Asthma Action Plan
Student Name__________________________ Teacher/Team_________________________

1. Triggers that might start an asthma episode for this student:
□ Exercise   □ Animal Dander               □ Cigarette smoke, strong odors □ Respiratory Infections
□ Pollens    □ Temperature Changes         □ Foods___________________ □ Emotions (e.g. when upset)
□ Molds      □ Irritants (e.g. chalk dust) □ Other_________________________________________________

2. Control of the School Environment:
____ Environmental measures to control triggers at school_______________________________
____ Pre-Medications (prior to exercise, choir, band, etc.)_______________________________
____ Dietary Restrictions_________________________________________________________

3. Peak Flow Monitoring

____ Monitor Peak Flow:
       Personal Best Peak Flow_________________ Monitoring Times________________
____ Do Not Monitor Peak Flow

4. Routine Asthma and Allergy Medication Schedule

                                                                When to Administer
  Medication Name             Dose/Frequency                At Home          At School

5. Field Trips: Asthma Medications and supplies must accompany student on all field
trips. Staff member must be instructed on correct use of the asthma medications and bring
a copy of the Asthma Action Plan and Contact Phone Numbers.

     (1) Parent to Contact _______________________________________________________
     Phone Number(s) __________________________________________________________
     (2) Other Person to Contact in Emergency _______________________________________
     Phone Number(s)___________________________________________________________

Parent/Legal Guardian Signature__________________________ Date ________________

Reviewed by the School Nurse ___________________________ Date ________________
             School Asthma Quick Relief & Emergency Plan
**Immediate action is required when the student exhibits any of the following signs of
respiratory distress. Always treat symptoms even if a peak flow meter is not available.
Severe cough      Shortness of Breath      Sucking in of the chest wall     Difficulty walking from breathing
Chest tightness   Turning blue             Shallow, rapid breathing         Difficulty talking from breathing
Wheezing          Rapid, labored breathing Blueness of fingernails & lips   Decreased or loss of consciousness

Steps to Take During an Asthma Episode:

1. Give Emergency Asthma Medications As Listed Below:

     Quick Relief Medications                  Dose/Frequency                   When to Administer


2. Contact Parents if___________________________________________________________

3. Call ________________ to activate EMS if the student has ANY of the following:

        Lips or fingernails are blue or gray
        Student is too short of breath to walk, talk, or eat normally
        No relief from medication within 15-20 minutes with any of the following signs
         • Chest and neck pulling in with breathing
         • Child is hunching over
         • Child is struggling to breathe
      Physician signature:_________________________________Date:___________________

                     Parent Consent for Management of Asthma at School
      I, the parent or guardian of the above named student, request that this School Asthma Action
      Plan be used to guide asthma care for my child. I agree to:
              1. Provide necessary supplies and equipment.
              2. Notify the school nurse of any changes in the student's health status.
              3. Notify the school nurse and complete new consent for changes in orders from the
                  student's health care provider.
              4. Authorize the school Nurse to communicate with _______________________,the
                  primary care provider/specialist about asthma/allergy as needed.
              5. School staff interacting directly with my child may be informed about his/her
                  special needs while at school.

             Parent/Legal Guardian Signature___________________________ Date __________
             Reviewed by School Nurse _______________________________ Date __________

To top